Director Quality and Accreditation - LV Durango Family Medicine Clinic - Full Time 8 Hour Days Exempt Non-Union

The Director is responsible for designing implementing and maintaining programs and practices to ensure the organization complies with applicable regulations and accreditation standards. The Director provides daytoday operational leadership and oversight of regulatory compliance to improve patient safety and reduce clinical risk. The Director acts as a resource for the organization regarding issues of quality improvement and regulatory standards and identifies strategic initiatives to support the organizations goals.

As a leader in the Culinary Health Operations the Director is responsible for designing implementing and maintaining programs and practices to ensure the organization complies with applicable regulations and accreditation standards. The Director provides operational leadership and oversight of regulatory compliance to improve patient safety and reduce clinical risk. The Director acts as a resource for the organization regarding issues of quality improvement and regulatory standards and identifies strategic initiatives to support the organizations goals. The Director will report directly to the Executive Administrator Culinary Health Operations and will be responsible for covering all Culinary Health Center locations.

Essential Duties:

• Designs implements and maintains programs and practices to ensure the organization complies with DNV TITLE 22 CMS and other applicable State and Federal regulations and accreditation standards.
• Oversees regulatory body surveys i.e. State licensing Reviews AAAHC Surveys.
• Stays current with AAAHC State and Local standards and educates facility staff about standard requirements and changes as they occur.
• Identifies develops and evaluates quality improvement initiatives particularly as they relate to regulatory programs
• Evaluates effectiveness of corrective actions for identified problems and continuous quality improvement activities.
• Serves on committees task forces and peer networks as appropriate.
• Trains and develops other departmental personnel in quality improvement and regulatory oversight including announced and unannounced mock surveys
• Ensures compliance with Local State and Federal reporting guidelines; ensures accuracy of all data prior to reporting
• Directs performance improvement initiatives within the health center and system.
• Directs onsite survey processes with regulatory agencies both announced and unannounced.
• Primary communicator with regulatory agencies.
• Communicates needs with administration and departmental leadership relative to implementation and compliance standards.
• Communicates with all accreditation agencies for any direction or questions relative to compliance or implementation as necessary to assure the center maintain survey readiness.
• Assures timely communication of regulatory and accreditation standards changes and updates to appropriate staff.
• Perform other duties as assigned

Required Qualifications:

• Req Bachelors Degree in Healthcare Business or related field

• Req 5 years Healthcare management experience with leadership roles in Clinical Operations Quality and/or Regulatory Compliance

• Req Knowledge of governing regulatory requirements.
• Req Working knowledge of Microsoft Office Suite including Outlook Word Excel and PowerPoint.
• Req Excellent oral and written communication skills with exemplary attention to detail.
• Req Excellent interpersonal skills to deal effectively and tactfully with people at all levels of management.

Preferred Qualifications:

• Pref Masters degree
• Pref Registered Nurse RN (CA Board of Registered Nursing)
• Pref Registered Nurse (NV NSBN) CA RN license not applicable to Nevada Culinary Operations

Required Licenses/Certifications:

• Req Fire Life Safety Training (LA City) If no card upon hire one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
• Req Certified Professional in Healthcare Quality CPHQ (NAHQ)

USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin protected veteran status disability or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance and with due consideration for patient and student safety. Please refer to theBackground Screening Policy Appendix Dfor specific employment screen implications for the position for which you are applying.

We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone ator by email at. Inquiries will be treated as confidential to the extent permitted by law.

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